Jung Typology AssessmentThe purpose of this assignment is to ass.docx

Jung Typology Assessment
The purpose of this assignment is to assess your personality and
how that information might help guide your career choice.
Understanding personalities can also help managers know how
to motivate employees.
Find out about your personality by going to the Human
Metrics website (www.humanmetrics.com - and TAKE the Jung
Typology Test - Jung, Briggs, Meyers Types. It is a free test.
(Disclaimer: The test, like all other personality tests, is only a
rough and preliminary indicator of personality.)
·
Complete the typology assessment
·
Read the corresponding personality portrait and career
portrait.
·
Think about your career interests, then answer the
following:
How are your traits compatible for your potential career choice
(Business Administration)? This should be around 250 words of
writing.
R E S E A R CH
Co-administration of multiple intravenous medicines: Intensive

care nurses' views and perspectives
Mosopefoluwa S. Oduyale MPharm1 | Nilesh Patel PhD,
BPharm (Hons)1 |
Mark Borthwick MSc, BPharm (Hons)2 | Sandrine Claus PhD,
MRSB, MRSC3
1Reading School of Pharmacy, University of
Reading, Reading, UK
2Pharmacy Department, John Radcliffe
Hospital, Oxford University Hospitals NHS
Foundation Trust, Oxford, UK
3LNC Therapeutics, Bordeaux, France
Correspondence
Mosopefoluwa S. Oduyale, Reading School of
Pharmacy, University of Reading, Harry
Nursten Building, Room 1.05, Whiteknights
Campus, Reading RG6 6UR, UK.
Email: [email protected]
Funding information
University of Reading
Abstract

Background: Co-administration of multiple intravenous (IV)
medicines down the
same lumen of an IV catheter is often necessary in the intensive
care unit (ICU) while
ensuring medicine compatibility.
Aims and objectives: This study explores ICU nurses' views on
the everyday practice
surrounding co-administration of multiple IV medicines down
the same lumen.
Design: Qualitative study using focus group interviews.
Methods: Three focus groups were conducted with 20 ICU
nurses across two hospi-
tals in the Thames Valley Critical Care Network, England.
Participants' experience of
co-administration down the same lumen and means of assessing
compatibility were
explored. All focus groups were recorded, transcribed verbatim,
and analysed using
thematic analysis. Functional Resonance Analysis Method was
used to provide a
visual representation of the co-administration process.
Results: Two key themes were identified as essential during the
process of co-admin-

istration, namely, venous access and resources. Most nurses
described insufficient
venous access and lack of compatibility data for commonly used
medicines (eg, anal-
gesics and antibiotics) as particular challenges. Strategies such
as obtaining additional
venous access, prioritizing infusions, and swapping line of
infusion were used to man-
age IV administration problems where medicines were
incompatible, or of unknown
or variable compatibility.
Conclusions: Nurses use several workarounds to manage
commonly encountered
medication compatibility problems that may lead to delays in
therapy. Organizations
should review and tailor compatibility resources towards
commonly administered
medicines using an interdisciplinary approach. Developing a
clinical decision-making
pathway to minimise variability while promoting safe co-
administration practice
should be prioritised.
Relevance to clinical practice: This study highlights several

ways ICU nurses are able
to manage challenges associated with co-administration and the
need for the devel-
opment of a more robust and comprehensive compatibility
resource that is relevant
to everyday practice through collaboration between nurses and
pharmacists.
Received: 17 July 2019 Revised: 25 November 2019 Accepted:
20 December 2019
DOI: 10.1111/nicc.12497
This is an open access article under the terms of the Creative
Commons Attribution License, which permits use, distribution
and reproduction in any medium,
provided the original work is properly cited.
© 2020 The Authors. Nursing in Critical Care published by John
Wiley & Sons, Ltd on behalf of British Association of Critical
Care Nurses.
156 Nurs Crit Care. 2020;25:156–
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K E YWORD S
co-administration, compatibility, functional resonance analysis
method, intravenous
1 | BACKGROUND
Patients admitted to intensive care units (ICU) are prescribed
numerous
medicines delivered by continuous intravenous (IV) infusion.
The num-
ber of prescribed IV infusions usually exceeds the number of
venous
access sites or available lumens. Intensive care nurses are then
forced to
request additional venous access, or alternatively co-administer
either
continuous or intermittent infusions down the same lumen using
a
Y-site connector, meaning the medicines mix in the venous
access
lumen before entering the bloodstream. Medicines administered
in this
way are at risk of physicochemical incompatibilities. Medicine
incompat-

ibilities are considered to be in vitro physical or chemical
reactions that
occur between two or more IV medicines combined in the same
cathe-
ter lumen.1 Physical incompatibilities cause visible changes,
often pre-
senting as precipitates, whereas chemical incompatibilities are
not
visible and are considered significant when more than 10%
degradation
of one or more of the medicines in solution occurs.2
Physicochemical reactions may impair the therapeutic efficacy
of
the medicines or result in venous catheter occlusion, toxic
compound
formation, embolism, or local/systemic inflammatory
reactions.1,3-6
There are cases of life threatening pulmonary embolism,
ventricular
failure, and ineffective therapy in humans, prompting the Food
and
Drug Association to issue safety alerts.7-11 These adverse
effects

harm patients and increase costs for hospitals.12 Thus,
compatibility
must be assured prior to the co-administration of medicines.
Nurses are at the forefront of co-administration practice;
however,
the majority of co-administration studies focus on frequencies
of com-
bining incompatible medicines, generation of compatibility
data, and
clinical complications of incompatibilities13-16 (Benlabed et al,
2018).
There is an evidence gap regarding nurses' experience of
processes
involved in co-administration of multiple medicines down the
same
lumen and potential challenges experienced. Because the
problem is
common,17 an understanding of the process based on nurse
experiences
could prove useful by improving our knowledge, and revealing
potential
practical interventions. This could help make patient care more
efficient,
minimise challenges encountered by nurses during the process

of co-
administration, and ultimately promote safer co-administration
practice.
Co-administration of multiple medicines down the same lumen
can
be viewed as a complex socio-technical system involving
interaction
between people, technology, and devices in a physical and
organisational
environment. Viewed like this, outcomes of services provided
are inter-
connected and non-linear,15 and so can be investigated using a
non-linear
method such as Functional Resonance Analysis Method
(FRAM).16 The
FRAM results in a model that is a visual representation of all
the activities
connected to the process of co-administration of medicines.
Using FRAM
reveals interconnections and adjustments made within work
processes
that a linear approach may be unable to discover. A key
advantage of
FRAM is that it can be used to assess how things go right as

well as how
things go wrong. This helps to identify not only what happens
in the pro-
cess, but also the “how” and “why” aspects of the process.17
Several
studies show FRAM to be useful in exploring the effectiveness
of work
systems and in understanding everyday performance in health
care
processes to inform guideline implementation.17,21,22
Therefore, FRAM may provide new perspectives on the process
of co-administration which can then be used to improve the
system
of work, quality, and safety of patient care.
2 | AIM
The overall aim was to explore the everyday practices
surrounding co-
administration of multiple IV medicines by ICU nurses down
the same
lumen, the challenges encountered during the process of co-
administration,
and investigate how compatibility is assessed andmanaged in
practice.

WHAT IS KNOWN ABOUT THIS TOPIC
• Co-administration of multiple medicines down the same
lumen is a common practice in ICUs.
• There are several potential complications associated with
co-administering incompatible medicines down the same
lumen, and so compatibility must be determined prior to
co-administration.
WHAT THIS PAPER ADDS
• This study indicates that nurses adopt several
workarounds to manage the challenges associated with
co-administration through requesting additional venous
access, prioritising infusions, and spacing out doses
• This study has used the Functional Resonance Analysis
Method (FRAM) to visualise the process of co-
administration which can be adapted to develop a user
friendly decision-making pathway for co-administration
to minimise variability in practice
• This study shows that resources available have limited

compatibility data on commonly used medicines. Future
compatibility studies should focus on providing data
based on current clinical practice.
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3 | DESIGN AND METHODS
This study used a qualitative research design through the use of
focus
groups to explore how ICU nurses simultaneously co-administer
medi-
cines down the same lumen and the means by which
compatibility is
determined in practice. Focus groups were undertaken to allow
peo-
ple with similar experiences (ie, nurses) and to identify shared
and
common knowledge. Encouraging comments and sharing of
views
with each other can provide more in-depth responses and also
enable

participants to reflect on their practice.23,24
3.1 | Setting and sample
Three focus groups were conducted with ICU nurses across two
hos-
pitals with adult ICUs in the Thames Valley Critical Care
Network. An
estimate of 65 ICU nurses were invited to participate in the
study.
Within the nursing group, purposeful sampling was employed to
ensure that only qualified ICU nurses with work experience in
an ICU
setting were invited because of their experience and knowledge
in co-
administration of IV medicines (Table 1). We aimed for four to
eight
ICU nurses for each focus group because this is shown to be the
most
appropriate size.23 All ICU nurses at each hospital were invited
to take
part in the study via email using ICU pharmacists and matrons
as con-
tacts at both hospitals. The ICU nurses that indicated interest in
par-

ticipating were contacted by the first author—(M.S.O.) directly
and
convenient times were arranged for the focus groups.
3.2 | Data collection tools
A focus group schedule consisting of semi-structured questions
was
used to guide the discussion, allowing for probing questions and
clari-
fication where appropriate.23,25 Focus groups were conducted
between October 2017 and July 2018. Each focus group
discussion
took place in a meeting room at the hospital away from the ICU
wards
and lasted between 40 and 60 minutes. Each focus group was
facili-
tated by M.S.O. The main questions asked were (a) “Can you
tell me
about a time where you have had to combine multiple IV drugs
down
the same lumen?” and (b) “How do you check for IV
compatibility?”
Each focus group was audio recorded with consent from
participants,

anonymised, and transcribed verbatim by M.S.O. Field notes
were
made after each focus group by M.S.O.
3.3 | Data analysis
3.3.1 | Thematic analysis
The transcribed data were entered into the qualitative data
analysis
software NVivo 12 (NVivo qualitative data analysis software;
QSR
International Pty Ltd. Version 12, 2018) for data management,
and
analysed thematically for codes and themes. Thematic analysis
of data
followed six steps as described by Braun and Clarke;
familiarizing one-
self with the data, generating initial codes, searching for
themes,
reviewing themes, naming, and defining themes.26 Two
researchers
(M.S.O. and N.P.) were involved in the thematic analysis of the
data.
The initial codes were developed inductively, in that they were
driven

from the data and not by any pre-existing theory or coding
frame-
work. The initial codes were identified by M.S.O., iteratively
refined
within the research team, and collated into potential, and final
themes
by both M.S.O. and N.P. Codes were not returned to nurses for
validation.
3.3.2 | FRAM: Building the FRAM model
The FRAM model was built using the FRAM model Visualiser
tool.
There are five steps involved in developing a FRAM model. The
first
step is to identify the primary purpose of the FRAM analysis
and iden-
tify functions that are essential for work to be carried out. In
this case,
FRAM was used to demonstrate co-administration practice. The
sec-
ond step is to identify the functions that are required for
everyday
activities and how each function relates to another. Functions in
this

context refer to people's actions to achieve or perform a specific
task
either individually or collectively. The functions were identified
by
TABLE 1 Participants' demographics
Job role
Years of work
experience in
ICUs (year) Department of ICU
Staff nurse 3 years Adult and Cardiothoracic
Staff nurse 2 years Adult (general)
Staff nurse 6 years Adult and Cardiothoracic
Staff nurse 2 years Adult
Senior sister 17 years Adult
Staff nurse 1 year Adult and Cardiothoracic
Registered
nurse
4 years Adult
Staff nurse 1 year Adult
Staff nurse 2 years Adult

Staff nurse 1 year Adult and Cardiothoracic
Deputy
sister
18 years Adult
RAF nurse 2 years Adult
Staff nurse 1 week Adult
Staff nurse 8 months Adult
Staff nurse 8 years Neuro, Trauma, Cardio and
General
Deputy
sister
13 years General
Staff nurse 8 months Adult
Staff nurse 2 years and
8 months
Adult
Abbreviations: ICU, intensive care unit; RAF, royal air force.
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M.S.O., by thematically analysing the data and identifying
codes that
were integral to the process of co-administration. The codes
gener-
ated are represented as functions in the FRAM model. The third
step
involves identification of performance variability, the reason
for vari-
ability, and potential impact on a work system. The fourth step
involves determining how variability can spread throughout the
sys-
tem leading to either an unexpected or expected outcome known
as
functional resonance. The final step is to develop
recommendations
for monitoring and managing performance variability to
diminish the
possible occurrence of unwanted outcomes.
3.3.3 | Respondent validation
Nurses who participated in the focus groups were invited to
assess

the accuracy and reliability of the resulting FRAM model
(respondent
validation). Participants were requested to review the model,
and a
meeting time was arranged. Participants were asked to verify
the
model's accuracy and to indicate whether important elements
were
missing or insignificant elements had been included.
4 | ETHICAL AND RESEARCH APPROVALS
Ethical approval from University of Reading Ethical Committee
was
received on 04/08/2017 (Ref number 17/37). Study participation
was
voluntary, no financial incentives were given. Written consent
was obtained from all participants before taking part. Each
participant
was allocated a number to ensure anonymity during coding
processes,
and all data kept confidential.
5 | RESULTS
A total of 20 ICU nurses participated in the study, 18 of which

pro-
vided demographic data. Focus groups consisted of two to eight
ICU
nurses. The years of ICU experience ranged from 1 week to 13
years.
Adult ICUs were the most common wards that nurses worked in
(Table 1).
Thematic analysis highlighted two major themes, namely,
venous
access and resources.
The FRAM model represents the activities carried out by ICU
nurses from the moment a patient is admitted into the ICU to
the
point of IV administration. The model ends when IV
administration
has occurred and shows that co-administration is a complex
process
with several interdependencies.
A total of 21 functions were identified as important for co-
administration in the FRAM model. A visual representation of
the
model can be found in Figure S1, and shows many

interrelationships
between several functions.
6 | VENOUS ACCESS
6.1 | Creating venous access
Participants reported that the type of catheter inserted for
continuous
IV delivery was dependent on the number of medicines
prescribed
and their strength. The use of multi-lumen central venous
catheters
was found to be the most advantageous as they consolidate
infusions
of more than one medicine independently while limiting the
number
of invasive devices on the patient, in turn minimising the risk of
infection.
You want to restrict the amount of invasive devices
you have on the patient - so you don't want to have
4 cannulas in the patient plus a central lumen unless
you have a really good reason - because the more inva-
sive devices, the more risk of infection… (Partici-

pant 9)
6.2 | Availability of venous access
A major concern was the availability of sufficient venous
access, espe-
cially in patients who have been prescribed a multitude of
medicines
requiring continuous infusions. Participants stated a preference
for
the administration of one medicine per lumen. This was not
always
possible as the number of prescribed medicines for continuous
infu-
sions sometimes exceeded the available lumens.
I would rather have just the one on one lumen and… so
yeah if I have enough lumen… I'll just split everything
up… (Participant 19)
Participants explained that there were certain medicines
prescribed
for continuous infusions that can neither be disrupted (eg,
vasopres-
sors) nor combined with other medicines (eg, blood products,
total

parenteral nutrition). These medicines must be allocated to a
desig-
nated lumen in order to prevent accidental bolusing or
withdrawal of
the infusion, limiting the number of lumens available for
continuous
infusion.
You have your inotropes and vasopressors you have
them specifically on one port….to avoid any accidental
blousing…. So it's kinda like one dedicated lumen…this
is for ionotropes or vasopressants only (Participant 2)
6.3 | Additional venous access
Requesting the insertion of an additional cannula was described
by
participants as the easiest and quickest option for administration
when venous access was limited.
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But most of the time when we have that many medi-

cines that you have no entry point on the patient then
it's normally quicker to ask the doctor if they can just
put another cannula for you… (Participant 18)
However, they described that this could become a difficult
solution,
especially when doctors were not readily available. One
participant
mentioned that sometimes doctors had to be approached
multiple
times before the request could be granted. In desperate circum-
stances, some participants mentioned that they had to go higher
up
and ask a consultant for assistance, which could take up to a
couple of
hours.
Just being persistent with the doctors that I need a
venflon, I haven't given the antibiotics– it was due like
half an hour ago and… I don't want to delay it… or if
that person is not going to do it, you just have to go to
higher up (Participant 20)

Despite strategies to maximise venous access, participants
sometimes
ran out of sufficient venous access. They reported that when
venous
access was limited or compatibility information was
unavailable, some
continuous infusions (insulin, electrolyte fluids, or vitamins)
were
stopped to allow for the administration of intermittent
medicines per-
ceived to be of higher priority, such as antibiotics and
analgesics. Partici-
pants expressed that this can be frustrating and results in
disruption in
prescribed administration times, as each medicine had to be
adminis-
tered one at a time through a designated lumen after flushing
with
saline at every interval because of the uncertainty of
compatibility.
If you have medicines which are urgent, say… antibi-
otics. You'd end up having to stop other infusions and
prioritising which ones more important (Partici-

pant 15)
Administering one medicine after the other meant that the
partici-
pants had to space out doses, sometimes causing a delay in
adminis-
tration of other medicines. One participant reported that making
changes to administration times is one of the reasons
administration
errors are made.
Infusions take a long time and we are constantly
supplementing these things…” (Participant 11)… “and
we are delaying medicines as a result, and it ruins it for
the rest of the medicine charts and then errors are
made (Participant 7)
However, the majority of participants were not overly
concerned
about delays in administration, and did not think that this would
affect
patient care or recovery. This was because of their perception
that
delayed administration can be compensated for by adjusting
adminis-

tration times to ensure the correct dose is given within the
minimum
time frame. Additionally, there was the view that because
patients are
constantly monitored, and with their knowledge about
medicines,
adverse effects can be identified early and reversed quite
quickly.
Well maybe if afternoon dose is like delayed for 2 hours
then we'll delay the evening one with an hour… but we
sort of do makeup in the 24hrs that they do get the
exact same amount (Participant 19)
The majority of participants reported that some medicines can
be
administered peripherally instead of centrally. If these
medicines were
being administered centrally, they could be swapped to a
peripheral
catheter to create space for medicines that can only be
administered
centrally.
7 | RESOURCES

Participants highlighted the importance of checking
compatibility prior
to co-administering multiple medicines through Y-site
connectors. For
familiar medicine combinations, compatibility was largely
confirmed
from nurse experience rather than using a compatibility
resource. For
example, propofol and fentanyl were described as routine
combina-
tions known to be compatible; therefore, participants felt it
unneces-
sary to check compatibility using a resource.
I don't use it (compatibility chart) that often if it is a
fairly standard set of drugs that I normally know,
because you get into the experience of which things
go in which things (Participant 9)
However, for unfamiliar medicines, compatibility was checked
for
potential medicine combinations using a reference source.
Partici-
pants reported a variety of resources for checking compatibility

such
as a locally produced compatibility chart, drug monographs, the
phar-
macy team, a more experienced nurse, or an in-house medicines
man-
agement policy guide as can be seen in the extracted FRAM
model in
Figure 1.
The compatibility chart was the preferred reference source
because of availability, and was described as easy to use with
the abil-
ity to check compatibility multiple times for a variety of
medicine
combinations.
The chart is quicker because you look at it straight
away… (Participant 20)
Participants identified a limitation of the chart being a
restricted num-
ber of medicines, with little to no information available for
some regu-
larly used medicines. They also mentioned that the resources
available

report two medicine combinations but on some occasions may
want
to combine three medicines down the same lumen for which
they
confirm compatibility by cross-referencing medicine pairs on
the com-
patibility chart. However, participants stated that they would
not
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combine medicines that resources reported to be incompatible,
unknown, or variable as per advice from the pharmacy team.
I find smaller medicines like the paracetamol, metroni-
dazole and things like that, they are not on our com-
patibility chart (Participant 2)
…Say you have Hartmann's, propofol and fentanyl….
you would have to do Hartmann's against propofol,
Hartmann's against fentanyl and propofol against fen-
tanyl (Participant 8)

The way in which participants made their decisions sometimes
varied
and this can be seen in Figure 1. For example, should a
participant not
find information on the chart, they might next check the drug
mono-
graph followed by a request for additional venous access before
administration and vice versa.
8 | RESPONDENT VALIDATION
Responses were received from six ICU nurses, five of which
were
involved in the original focus groups. Respondents thought that
the FRAM model was comprehensive and an accurate
representa-
tion of work as performed in everyday practice. However, two
new functions were added to the FRAM model as advised by the
nurses; <to assess number of infusions> and <drug monograph>
as
some participants mentioned using the drug monograph to check
compatibility.
9 | DISCUSSION

Our findings suggest that the absence of compatibility data and
insuf-
ficient venous access appear to be the main challenges
associated
with IV medicine co-administration. Participants managed these
through workarounds such as requesting additional venous
access,
prioritising infusions, swapping line of infusion, and changing
the form
of medicine. These have also been identified in other
studies.14,27
F IGURE 1 Extract from the Functional Resonance Analysis
Method model showing the various ways compatibility can be
assessed
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Workarounds are alternative work procedures devised to
circumvent
a perceived workflow block, which may become necessary for
tasks
to be accomplished safely in variable environments such as
health

care.28,29 However, there are concerns that workarounds may
create
new pathways to error and decrease patient safety by increasing
the
likelihood of administration errors.30-33 Koppel et al31
examined medi-
cines administration by nurses using a Barcode Medication
Adminis-
tration system, identifying 15 types of workarounds with
potential for
administering the wrong medications and at wrong times. A
possible
consequence of workarounds in our study is medicine
administration
delays, which the National Patient Safety Agency considers to
be a
significant patient safety issue.34 Administration delay can
have a det-
rimental impact on patient recovery, especially with medicines
such as
antibiotics.34 Future work could use the FRAM model to
identify areas
of potential safety risks associated with workarounds.35,36
Each workaround involved a clinical decision-making process

which
was variable and depended on nurses' experience and
organisational
factors. The vast majority of participants used experience to
confirm
compatibility, only using other resources with medicines
unfamiliar to
them. Pattern recognition could be a possible explanation for
this, where
nurses were able to make a clinical decision based on previous
knowl-
edge of using similar medicine combinations in patients they
had cared
for.37 However, a drawback is that participants may be relying
on mem-
ory cues associated with inaccurate information, thereby risking
combin-
ing incompatible medicines. Organisational factors such as
institutionalised routines, resource and staff availability can
influence
the development of workaround behaviours.38,39 In this study,
workarounds appear to have become embedded into everyday
nursing

practice. While it is unclear if these workarounds are without
risks, their
constant use can be used to highlight areas within organisations
that
require practical interventions to improve work efficiency. For
example,
we found that obtaining additional venous access was heavily
depen-
dent on doctor availability, which sometimes delayed medicine
adminis-
tration. This could be resolved by promoting peripheral
cannulation by
senior nurses within organisations.
Given the complexity of co-administration of medicines in the
ICU setting, a clinical decision-making pathway or tool for
assessing
compatibility prior to co-administration that includes steps to
follow
when compatibility is unknown, variable or incompatible should
be
made available. This could be especially useful for new
members of
staff unfamiliar with different co-administration practices, and
to stan-

dardise the workarounds utilised to reduce the chances of
creating
new, more harmful workarounds. The FRAM model can be used
to
inform a simplified user-friendly decision-making pathway as it
reflects everyday work as performed in practice. Clay-Williams
et al40
used FRAM to develop guidelines compatible with how staff
work,
and through this found that the need to create workarounds that
compromised safety and quality of care could be reduced.
Although the compatibility chart was described as useful, there
was a need for more comprehensive compatibility data to be
included
in the chart.41 This is supported by findings from a systematic
review
investigating the availability of physical and chemical
compatibility
data for commonly used medicines in ICU.42 Virtually no data
exists
for three medicine combinations, and participants reported
reluctantly

co-administering three medicines if they had been previously
adminis-
tered without reports of clinical complications. This approach is
largely
based on physical compatibility, but there are concerns that not
all
incompatibility is physical. It would be worthwhile exploring
and con-
firming the chemical compatibility of IV medicines alongside
physical
compatibility. Additionally, future compatibility studies should
explore
providing compatibility data for potential three medicine
combina-
tions to minimise the risk of combining incompatible medicines
and
help to improve work efficiency.
Our findings suggest that the compatibility chart in use requires
an update. Because of the possibility of numerous medicine
combina-
tions, compiling and producing an updated chart can be arduous.
Nurses’ input in updating the chart would likely be beneficial to
develop a resource that is relevant to current practice. Strategies

such
as including physicochemical properties (eg, pH) within the
chart with
additional training on the significance of the values included
may help
bedside care givers with predicting incompatibilities. However,
pH
reactions are not always definitive in measuring compatibility
and so
visual monitoring of lines for precipitates is still likely to be
required.
A strength of this study is that it directly takes into
consideration
the experiences and perspectives of ICU nurses in understanding
the
practice surrounding co-administration of multiple medicines
down
the same lumen, alongside identifying key challenges associated
with
co-administration. The use of FRAM highlights the
interrelations
within the process and how variability occurs within the system.
Limitations of the study include being conducted within two
hospi-

tals in the same critical care region, and therefore, perspectives
and
experiences of the ICU nurses may not reflect practice across
all
hospitals. More research to obtain an overall understanding of
co-administration practice across a wider range of hospitals is
required.
The presence of senior staff members in the focus groups could
have
prevented some junior nurses from expressing their opinions
and co-
administration practice freely. A regional compatibility chart
was the
main resource used by participants in this study. However, the
chart may
not be a standard resource in all hospitals. Further research to
investi-
gate resources used in other hospitals, their effectiveness, and
potential
limitations, in comparison with the compatibility chart is
warranted.
10 | IMPLICATIONS AND
RECOMMENDATIONS FOR PRACTICE

The FRAM can be used to inform a user friendly decision-
making
pathway to potentially standardise workarounds in practice,
promot-
ing safer patient care.
Organisations should consider reviewing and designing
compati-
bility charts of commonly used medicines using an
interdisciplinary
approach to create a comprehensive tool that is relevant to
everyday
practice.
Future compatibility studies should consider compatibility
assess-
ment of three medicine combinations.
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ACKNOWLEDGEMENTS
The authors would like to thank all the ICU nursing staff who
partici-
pated in the focus groups for sharing their views and

experiences.
Funding was received from the University of Reading PhD
studentship.
AUTHOR CONTRIBUTIONS
M.S.O. designed the focus group questions, arranged and
conducted
the focus groups, and analysed and interpreted the study data.
The
data analysis and interpretation was reviewed by N.P. M.S.O.
drafted
the paper and all authors contributed to the subsequent drafts
and
final version of the manuscript.
11 | CONCLUSION
The majority of nurses described lack of sufficient venous
access and
compatibility data for commonly used medicines as challenges
associ-
ated with co-administration of multiple medicines down the
same
lumen. The use of FRAM highlighted workarounds used to
facilitate

administration of IV medicines that may sometimes lead to
delays in
therapy. The FRAM model can be used to develop a user
friendly clini-
cal decision-making pathway for co-administration of multiple
medi-
cines for use in organisations, which could standardise
workaround
behaviours while improving efficiency and safety of patient
care.
Future work should consider reviewing and designing
compatibility
resources with input from ICU nurses to create robust and
compre-
hensive compatibility resources that are relevant to everyday
practice.
ORCID
Mosopefoluwa S. Oduyale https://orcid.org/0000-0003-1482-
7239
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SUPPORTING INFORMATION
Additional supporting information may be found online in the
Supporting Information section at the end of this article.
How to cite this article: Oduyale MS, Patel N, Borthwick M,
Claus S. Co-administration of multiple intravenous medicines:
Intensive care nurses' views and perspectives. Nurs Crit Care.
2020;25:156–164. https://doi.org/10.1111/nicc.12497
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ity%20Chart%20v2.1.pdf
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https://doi.org/10.1111/nicc.12497Co-administration of multiple
intravenous medicines: Intensive care nurses' views and
perspectives1 BACKGROUND2 AIM WHAT IS KNOWN
ABOUT THIS TOPIC WHAT THIS PAPER ADDS3 DESIGN
AND METHODS3.1 Setting and sample3.2 Data collection
tools3.3 Data analysis3.3.1 Thematic analysis3.3.2 FRAM:
Building the FRAM model3.3.3 Respondent validation4
ETHICAL AND RESEARCH APPROVALS5 RESULTS6
VENOUS ACCESS6.1 Creating venous access6.2 Availability
of venous access6.3 Additional venous access7 RESOURCES8
RESPONDENT VALIDATION9 DISCUSSION10
IMPLICATIONS AND RECOMMENDATIONS FOR
PRACTICEACKNOWLEDGEMENTS AUTHOR

CONTRIBUTIONS11 CONCLUSIONREFERENCES
Vol. 5 | Issue 2 | March-May 2014 Journal of Basic and
A clinical study on drug-related problems associated with
intravenous drug administration
Abstract
Background: Infusion therapy through intravenous (IV) access
is a therapeutic option used in the treatment of
many hospitalized patients. IV therapy is complex, potentially
dangerous and error prone. The objectives were
to ascertain the drug‑related problems (DRPs) involved in IV
medication administration and further to develop
strategies to reduce and prevent the occurrence of DRPs during
IV administration.
Materials and Methods: A prospective observational study was
carried out for a period of 4 months. Patients
receiving more than two medications through IV route were
included and studied.
Results: Of 110 patients, 76 (69.09%) were male and the rest
were female. Nearly, half of the patients (46.3%, n = 51)
were reported with DRPs. Of the 80 DRPs (72.72%)
documented, 61 problems (55.4%) were seen in patients
given IV medications through peripheral line. Among the DRPs
majority seen were incompatibilities (40.9%,
n = 45), followed by complications developed (12.7%, n = 14),
errors in rate of administration (10.9%), and
dilution errors (8%). To study the association of DRPs among
gender, statistical analysis was performed and
significant association was seen between DRPs and gender (P =
0.03).

Conclusion: Among the reported DRPs, simultaneous IV
administration of two incompatible drugs was the main
predicament faced.
Key words:
Drug‑related problems, error, intravenous
A. Vijayakumar, E. V. Sharon, J. Teena, S. Nobil, I. Nazeer
Drug and Poison Information Center, Department of Pharmacy
Practice,
KMCH College of Pharmacy, Coimbatore, Tamil Nadu, India
Address for correspondence:
Mr. A. Vijayakumar,
Drug and Poison Information Center, Department of Pharmacy
Practice,
KMCH College of Pharmacy, Coimbatore ‑ 641 048, Tamil
Nadu, India.
E‑mail: [email protected]
Introduction
Intravenous (IV) therapy is complex, potentially dangerous
and error prone, thus the need for strategies to reduce the risk
and complications.[1] Infusion therapy through IV access is a
therapeutic option used in the treatment of many hospitalized
patients.[2] Infusion medications are associated with high risk
of harm. Once injected, reversal is almost impossible unless an
antidote exists.[3] The IV route of medication administration
has many advantages and benefits. The most important are
the immediate therapeutic effect of medications. It can sustain
high plasma drug levels and may be used when a person has
difficulty in swallowing.[4] The drug when given intravenously
will reach the target rapidly.[5] Thus, IV route is the preferred

route when the patient is critically ill. However, there are
also a lot of possible direct and negative side effects such as
pulmonary complications, thrombophlebitis, and infection
with the possibility of sepsis.[4] There have been reports of
death and harm following medication errors such as wrong
dose drug diluents and cross contamination errors. Thus,
the primary focus should be to identify IV therapy associated
drug‑related problems (DRPs).[3]
Drug‑therapy problems in intravenous
administration
Drug‑therapy (related) problem can be defined as an event
or circumstance involving drug treatment that actually
or potentially interferes with the patient experiencing an
optimum outcome of medical care.[6] DRPs can originate when
prescribing, dispensing or administering medications. It may
lead to substantial morbidity and mortality as well as increase
the health care expenditure, thus affecting both patients and
the society.[7]
Wrong diluents
In the German and French hospitals, the most frequent error
was preparing the medicine with the wrong diluents. The use
Original Article
Access this article online
Website:
www.jbclinpharm.org
Quick Response Code
DOI:

10.4103/0976-0105.134984
Vijayakumar, et al.: Drug related problems in IV administration
Journal of Basic and Clinical Pharmacy Vol. 5 | Issue 2 | March-
of the wrong diluents may cause a reduction in the solubility
of the medicine powder being reconstituted that can lead to
powder particulates being administered to the patient. The use
of the wrong diluents can also lead to a reduction in the
stability
and activity of medicine and possible drug precipitation.[8]
Incompatibilities
Intravenous access is usually limited and often need to
have medications administered simultaneously through the
same line. This is facilitated by a y‑site connector where the
medications mix in the lumen of the tubing for up to 1 min
prior to being infused into the patient. Not all medications
can be mixed together as all are not compatible with each
other.[9] Incompatibility is an undesirable reaction that occurs
between the drug and the solution, container or another drug.
Administering incompatible medications together through
the same line can result in negative consequences and even
death in some extreme cases.[10] The three incompatibilities
associated with IV administration are physical, chemical and
therapeutic incompatibility.[11]
Wrong rate and wrong time errors
It was reported that at UK hospitals, the most frequent IV
medication errors were related to the administration rate,
usually higher than that recommended. The administered

drug characteristics, fast rates of drug administration are
associated with pain, phlebitis, and other complications.[8]
Complications of intravenous therapy
Intravenous therapy presents a potential risk to patient safety
with associated risks varying from minor complications to
death. As more number of patients are becoming acutely ill,
the numbers of patients requiring IV therapies are increasing.
Maintaining the patient’s vascular access throughout treatment
is difficult because a number of complications including
phlebitis,
infiltration, extravasations, and infections may occur.[12]
Complications increase hospital stays, duration of therapy, and
can also put the patients at risk of other medical problems.[13]
Pharmacist role in intravenous administration
The mission of the profession of pharmacy is to improve public
health through ensuring safe, effective, and appropriate use of
medications.[14] Clinical Pharmacist can play a significant role
in nurse training as an effective method to reduce the rate of
errors in the hospital. One obvious solution to aid in the process
of DRPs could be considering pharmacy services in IV product
preparation by implementing protocol prepared by Clinical
Pharmacist and establishment of reporting error systems.[15]
Pharmacist role to provide expert advice on compatibility
and stability for the use of multiple drugs if required for
IV administration, update staff on new clinical practice
guidelines and help to interpret guidelines as they apply to
patients with advanced illness. Thus, permanent supervision
and involvement of Clinical Pharmacist is important.[16]
Materials and Methods
A prospective observational study was carried out over the
duration of 4 months from April, 2013 to July, 2013 at Private

Corporate Hospital, Coimbatore, India and the study was
approved by Institutional Ethics Committee. The patients
who received more than two IV medications irrespective of
their age and gender were enrolled in our study. Patients from
Intensive Care Unit (ICU) and Oncology Department were
excluded from the study.
Definition, assessment, and description of
intravenous drug‑related problems
Intravenous DRP was defined as an error of using wrong
rate or dilution in the context of administering medications
intravenously. We addressed DRPs as wrong rate, wrong
dilution procedure, incompatibility complications developed
after IV administration. The subjects in this study were
classified based on their diagnosis into various departments
(Neurology, Cardiology, Endocrinology, Nephrology, Ortho
etc.). DRPs were further categorized based on type of IV
administration (IV bolus, continuous IV infusion).
Data collection
For each patient, basic demographic characteristics as
well as occurrence and descriptive factors of each IV
DRPs were documented into a structured case record
form. DRPs documented include incompatibilities, rate of
administration errors, dilution errors, and complications
developed. Incompatibilities were categorized into actual
and observed. Actual incompatibilities were referred
to those incompatibilities documented on a theoretical
basis from the medication chart, whereas observed
incompatibilities were referred to those incompatibilities
that were seen in patients. Confidentiality of the entire
patient’s data was maintained.
Statistical analyses
Drug‑related problems and its impact on gender and venous

access site, since patients were treated with central and
peripheral line were investigated. Data were analyzed by
using SPSS software version 14.0.1 manufactured by SPSS
Inc., Chicago, IL.
Results
A total of 110 patients were involved in this study during
the period of 4 months. The male (69.09%) population was
predominant when compared with the female population
[Table 1]. Majority of the male were seen in the age group of
60‑69 (15.45%) years, whereas female were seen mainly in the
age group of 40‑49 (9.09%) years.
The DRPs seen in our study population receiving IV
medications were incompatibilities, complications, rate
of administration error and dilution errors. Among the
110 patients, nearly half of the patients (46.3%, n = 51)
were reported with DRPs. Patients receiving IV medications
through peripheral line (82.72%, n = 91) was predominant
than those receiving central lines (17.27%, n = 19). Out of 80
DRPs (72.72%), 61 problems (55.4%) were seen in patients
given IV medications through peripheral line, whereas
19 (17.27%) DRPs were seen in patients given medications
through the central line [Table 2].
Among the DRPs majority were incompatibilities
(40.9%, n = 45), followed by complications developed
(12.7%, n = 14) after IV administrations, errors in the rate of

administration were accounted for 12 patients (10.9%) and
errors in the dilution accounted for nine patients (8%). The
incompatibilities documented were categorized into observed
and actual incompatibilities. Among the 45 incompatibilities
documented, 11.8% (n = 13) of the incompatibilities
were observed [Figure 1] and 29% (n = 32) were actual
incompatibilities. From the observed incompatibilities, the
most common reason for the cause of incompatibility was
the development of precipitate (10.9%, n = 12). Only one
incompatibility was attributed to color change over time.
The most common drugs involved in incompatibilities were
Pantoprazole, Phenytoin, Mannitol and Pipercillin. Based
on our observation and results, IV drug compatibility‑alert
card was prepared in order to enhance the rational use of IV
medication and patient safety [Figure 2].
The most common IV incompatibilities were reported
from Neurology Department (10.9%, n = 12), out
of which three were observed and nine were actual
incompatibilities. It was followed by Cardiology Department
(7.2%, n = 8), Endocrinology (5.4%, n = 6), Nephrology. Of
45 incompatibilities, majority of the incompatibilities were
seen between one bolus and an infusion (57.7%, n = 26),
incompatibilities between two IV bolus drugs were seen
in 35.55% of the incompatibilities (n = 16) and only three
incompatibilities involved two infusion drugs.
Discussion
This study was carried out to determine the DRPs involved in
IV medication administration and develop strategies to reduce
and prevent the occurrence of DRPs during administration of
IV medications. Such strategies will improve the quality of
preparation and administration of IV medications and reduce
the DRPs in the long run.

The predominance of patients receiving more than two IV
medications were male (69.09%, n = 76) and female receiving
more than two medications were only 30.90% (n = 34).
Our study results are more similar to the study conducted by
Ponni et al., results.[17]
Studies have reported that IV administration of drugs has a
higher risk and severity of errors than any other medication
administration.[18] The DRPs seen in our study population
receiving IV medications were incompatibilities, rate of
administration errors, dilution errors, and complications.
Incompatibilities were dominant than all other DRPs. Among
the 110 patients, nearly half of the patients (46.3%, n = 51)
were reported with DRPs. When compared to other European
studies,[18] it was observed that our study results indicated less
number of DRPs.
In a randomized control trial,[19] majority patients received IV
medications through peripheral line, but the DRPs were seen
mainly in patients with IV medications through the central
line. Whereas in our study, patients receiving IV medications
through peripheral line (82.72%, n = 91) was predominant
than those receiving central lines (17.27%, n = 19). Out of
the 80 DRPs (72.72%) seen, 61 problems (55.4%) were seen
in patients given IV medications through peripheral line,
whereas 19 (17.27%) DRPs were seen in patients given
medications via central line. Since, the study was carried out
only at general and specialty wards, not in ICU.
Direct observational studies performed in the United Kingdom
and Germany revealed overall error rates of 49% and 48%,
respectively.[18] Whereas among the DRPs in our study
majority seen were incompatibilities (40.9%, n = 45),
followed by complications developed (12.7%, n = 14) after
IV administrations, errors in the rate of administration were

Table 1: Gender wise association of variables in study
population
Variables Males Females Relative
risk
95% CI P value
Central line
No error 5 3 1.455 0.823‑2.568 0.1337
Error 10 1
Drug related
problems
Yes 41 11 1.307 1.016‑1.681 0.0360*
No 35 23
Infusion rate error
Yes 8 4 0.9608 0.6305‑1.464 0.8473
No 68 30
Error in dilution
Yes 8 1 1.320 1.010‑1.726 0.1798
No 68 33
Incompatibility
Yes 37 8 1.370 1.070‑1.740 0.0130*
No 39 26
Complications
Yes 13 1 1.410 1.153‑1.730 0.0390*
No 63 33
*P<0.05, CI: Confidence interval

Table 2: Intravenous access site association with
variables in study population
Drug‑related
problems
Central
line
Peripheral
line
Relative
risk
95% CI P value
Complications
Yes 4 10 1.829 0.7072‑4.728 0.2312
No 15 81
Error in dilution
Yes 1 8 0.6235 0.0937‑4.148 0.6098
No 18 83
Infusion rate error
Yes 3 9 1.531 0.5211‑4.500 0.4531
No 16 82
Incompatibilities
Yes 11 34 1.986 0.8679‑4.545 0.0978
No 8 57
CI: Confidence interval

Journal of Basic and Clinical Pharmacy Vol. 5 | Issue 2 | March-
accounted for 12 patients (10.9%) and errors in the dilution
accounted for nine patients (8%). In contrast, another study
revealed that wrong rate of administration was the most
frequent error, followed by omissions and wrong dose.[20]
Administering incompatible medications together through
the same line can result in negative consequences or death
in extreme cases.[9] The large number of incompatibilities
seen in our study may be due to lack of knowledge
regarding drug incompatibility and their consequences for
the patient.
Among the 45 incompatibilities documented, 11.8% (n = 13)
of the incompatibilities were observed and 29% (n = 32) were
actual incompatibilities. From the observed incompatibilities,
the most common reason for the cause of incompatibility
was the development of precipitate (10.9%, n = 12). Only
one incompatibility was attributed to color change over time.
The most common drugs involved in incompatibilities were
pantoprazole, phenytoin, mannitol, and piperacillin. The
study conducted by Kanji et al., were matched with our study
results.[9]
Results from different studies are difficult to compare
because of differing methods of analysis. Further to study
the significance of DRPs among gender, statistical analysis
was performed. Our results revealed that the relative
risk for all DRPs were >1. It indicates that there is a large
difference between the groups compared. Furthermore,
significant association was observed between total DRPs
and gender (P = 0.03). Similarly, when comparing DRPs

individually significant association was observed in case of
incompatibilities (P = 0.013) and complications (P = 0.039).
Increased complications seen in men possibly are due to the
high number of incompatibilities in men.
Even though, there was a difference between central and
peripheral line, we have performed statistical analysis to
know the risk of individual DRPs among patients with central
and peripheral line. It reveals that there was a significant
difference in cases of infusion rate error, complications and
incompatibilities. However, no significant association was
Intravenous drug incompatibility alert card
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e
Va
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om
yc
in
Acyclovir • C N C I C C C C C N I I C I C C
Amikacin C • I C C C C C C C C I I C C C C
Azithromycin N I • N I I N I N N N C N I I N N
Calciumgluconate C C N • N C I C N C C I I C C I C
Ciprofloxacin I C I N • I I I I N C I I C I I N
Clindamycin C C I C I • C C C C C I I C C C C
Dexamethasone C C N I I C • C C C C I I C C C N
Furosemide C C I C I C C • C C N I I C C C I
Hydrocortisone C C N N I C C C • C C I I C C C N
Mannitol C C N C N C C C C • C I I C C C C
Metaclopramide N C N C C C C N C C • I I C C C C
Pantoprazole I I C I I I I I I I I • I C I N I
Phenytoin I I N I I I I I I I I I • I I I I
Potassiumchloride C C I C C C C C C C C C I • C C C
Pippercillin tazobactam I C I C I C C C C C C I I C • C N
Sodiumbicarbonate C C N I I C C C C C C N I C C • N
Vancomycin C C N C N C N I N C C I I C N N •
C: Compatible, I: Incompatible, N: No data available •: Same

Drug
Figure 1: Intravenous Drug Incompatibility Alert Card
Figure 2: Intravenous drug incompatibility
3. Cousins DH, Upton DR. Medication error
79: How to prevent IV
medicine errors. Pharm Pract 1997;7:310-1.
4. BernaertsK, Evers G, Sermeus W. Frequency
of intravenous medication
administration to hospitalised patients: Secondary
data‑analysis of the
Belgian nursing minimum data set. Int J Nurs Stud
2000;37:101‑10.
5. Ong WM, Subasyini S. Medication errors
in intravenous drug
preparation and administration. Med J Malaysia 2013;68:52-7.
6. Mil FV. Drug related problems: A cornerstone
for pharmaceutical care.
J Malta Pharm Pract 2005;10:5-8.
7. Ruths S, Viktil KK, Blix HS. Classification of
drug‑related problems.
Tidsskr Nor Laegeforen 2007;127:3073‑6.

8. Cousins DH, Sabatier B, Begue D, Schmitt
C, Hoppe‑Tichy T.
Medication errors in intravenous drug preparation and
administration:
A multicentre auditin the UK, Germany and France.
Qual Saf Health
Care 2005;14:190-5.
9. Kanji S, Goddard R, Kanji S, Goddard
R, Donnelly R, McIntyre,
Turgeon A, Coons P, et al. Physical Compatibility of Drug
Infusions
used in Canadian Intensive Care Units: A Program of Research.
Canadian Patient safety Institute 2010.
10. Newton DW. Drug incompatibility chemistry. Am J
Health Syst Pharm.
2009; 66 (4): 348-357.
11. Cayo L. Compatibility of Commonly Used Intravenous
Drugs. In:
Pharmacy Practice News. 2010: 41-46.
12. Ingram P, Lavery I. Peripheral intravenous
therapy: Key risks and
implications for practice. Nurs Stand 2005;19:55‑64.
13. Complications of peripheral iv therapy. NMIE. 2008; 6 (1):
14-18.
14. Council on Credentialing in Pharmacy, Albanese NP, Rouse
MJ.
Scope of contemporary pharmacy practice: Roles,
responsibilities,
and functions of pharmacists and pharmacy technicians. J Am
Pharm

Assoc (2003) 2010;50:e35-69.
15. Majid AK. The roles of clinical pharmacy in reducing
medication
errors. Int Res J Pharm 2012;3:76-83.
16. Abbasinazari M, Zareh‑Toranposhti S, Hassani
A, Sistanizad M,
Azizian H, Panahi Y. The effect of information
provision on reduction
of errors in intravenous drug preparation and administration by
nurses
in ICU and surgical wards. Acta Med Iran 2012;50:771-7.
17. Ponni J, Acthyuth KY, Mohanta GP,
Kabalimurthy J. Studies
on the use of intravenous fluid management in
the first week of
post-operative period of gastrointestinal surgery. Indian J
Pharm
Pract 2012;5:16-20.
18. Westbrook JI, Rob MI, Woods A, Parry D.
Errors in the administration
of intravenous medications in hospital and the role of correct
procedures
and nurse experience. BMJ Qual Saf 2011;20:1027‑34.
19. Wilson D, Verklan MT, Kennedy KA. Randomized
trial of percutaneous
central venous lines versus peripheral intravenous lines. J
Perinatol
2007;27:92-6.
20. Wirtz V, Taxis K, Barber ND. An
observational study of intravenous

medication errors in the United Kingdom and in Germany.
Pharm
World Sci 2003;25:104‑11.
21. Taxis K, Barber N. Causes of intravenous medication errors:
An
ethnographic study. Qual Saf Health Care
2003;12:343‑7.
seen in patients receiving IV medications through central and
peripheral line (P > 0.05).
A European study reported that effective strategies are
needed to reduce the harmful errors during IV drug
administration.[21] Based on our observation and results,
IV drug compatibility‑alert card was prepared in order to
enhance the rational use of IV medication and patient safety.
Limitations
The study has certain limitations. Since it was a pilot
study, it was carried out in wards and did not include ICU.
Longer period of data collection from ICU, will definitely be
associated with other IV administration related DRPs. The
time of administration of certain IV medications was different
from the time of data collection. Such data were collected from
patient records and verbally from nurses. Further studies may
be carried out in a large sample size to predict more DRPs.
Conclusion
Although the majority of the DRPs do not cause significant
harmful clinical outcomes to patients, training needs as well
as plans should be proposed to reduce such complexity.
Among the DRPs, simultaneous IV administration of two
incompatible drugs was the main predicament faced. As
the outcome from the study, an IV drug compatibility‑alert

card was prepared and distributed to the wards to help and
minimize any confusion regarding the commonly used IV
drugs. It is recommended that check list should be introduced
in wards to encourage monitoring dilution and administration
rate of IV infusions. Thus, permanent supervision and
involvement of Clinical Pharmacist will improve the quality
of preparation and administration of IV medications and will
also reduce the DRPs.
Acknowledgments
The authors are gratefully thankful to Dr. Nalla G. Palaniswami,
Chairman and Managing Director of Kovai Medical Center and
Hospital, Coimbatore and Dr. Thavamani D. Palaniswami,
Trustee,
Kovai Medical Center Research Cancer and Educational Trust,
Coimbatore for providing necessary facilities and continuous
encouragement.
References
1. McDowell SE, Mt‑Isa S, Ashby D, Ferner
RE. Where errors occur in the
preparation and administration of intravenous medicines: A
systematic
review and Bayesian analysis. Qual Saf Health Care
2010;19:341‑5.
2. Summa‑Sorgini C, Fernandes V, Lubchansky S,
Mehta S, Hallett D,
Bailie T, et al. Errors associated with IV infusions in critical
care. Can
J HospPharm 2012;65:19‑26.
How to cite this article: Vijayakumar A, Sharon EV, Teena J,
Nobil S, Nazeer I.

A clinical study on drug-related problems associated with
intravenous drug
administration. J Basic Clin Pharma 2014;5:49-53.
Source of Support: Nil, Conflict of Interest: None declared.
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Evaluation of pharmacist interventions and
commonly used medications in the geriatric ward
of a teaching hospital in Turkey: a retrospective
study
Elif Ertuna, Mehmet Zuhuri Arun, Seval Ay, Fatma Özge
Kayhan Koçak,
Bahattin Gökdemir & Gül İspirli
To cite this article: Elif Ertuna, Mehmet Zuhuri Arun, Seval Ay,
Fatma Özge Kayhan Koçak,
Bahattin Gökdemir & Gül İspirli (2019) Evaluation of
pharmacist interventions and commonly used
medications in the geriatric ward of a teaching hospital in
Turkey: a retrospective study, Clinical
Interventions in Aging, , 587-600, DOI: 10.2147/CIA.S201039
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evaluation of pharmacist interventions and
commonly used medications in the geriatric
ward of a teaching hospital in Turkey:
a retrospective study

elif ertuna1
Mehmet Zuhuri Arun1
seval Ay2
Fatma Özge Kayhan Koçak2
Bahattin gökdemir2
gül İ spirli2
1Department of Clinical Pharmacy,
Faculty of Pharmacy, ege University,
Izmir, Turkey; 2Department of Internal
Medicine, Division of geriatrics,
Faculty of Medicine, ege University,
Izmir, Turkey
Purpose: Aging increases the prevalence of diseases. The
elderly population is consequently
often exposed to complex medication regimens. Increased drug
use is one of the main reasons
for drug-related problems (DRPs). The primary objective of this
study was to define and classify
DRPs, pharmacist interventions, and frequently prescribed
medications in relation to possible
DRPs in patients admitted to the geriatric ward of a teaching
hospital in Turkey.
Patients and methods: Pharmacist medication review reports for

200 orders of 91 patients
(mean age: 80.33±0.46) were analyzed retrospectively.
Results: A total of 1,632 medications were assessed and 329
interventions were proposed for
possible DRPs in 156 orders. A total of 87.5% of the patients
used five or more drugs (mean:
8.17±0.23). The number of DRPs per order was higher when
polypharmacy was present
(1.04±0.15 vs 1.66±0.11, P,0.05). In 71.31% of the cases,
adverse drug events were recog-
nized as the problem. The principal cause of possible DRPs was
determined as drug interactions
(40.12%). Only 22 potentially inappropriate medications were
prescribed. The most common
interventions included monitoring drug therapy (31.0%),
stopping the drug (20.06%), and chang-
ing dosage (13.98%). The acceptance rate of pharmacist
interventions by treating geriatrician
was 85.41%. The most frequently prescribed drugs were for the
nervous system, alimentary
tract and metabolism, and cardiovascular system (n=358, 314,
and 304, respectively). The
pharmaceutical forms of 23 drugs were deemed inappropriate by
pharmacists.

Conclusion: Clinical pharmacy services are still not properly
implemented in Turkey. The
study highlights ways in which clinical pharmacy services can
be instrumental in a geriatric
ward. The high acceptance rates of pharmacist recommendations
concerning a wide variety of
DRPs and different classes of drugs indicate that advanced
collaboration among geriatricians
and pharmacists is possible in interdisciplinary geriatric
assessment teams in Turkey.
Keywords: pharmaceutical care, clinical pharmacy, elderly,
medication review, polypharmacy,
potentially inappropriate medication
Introduction
According to the United Nations’ World Population Prospects
report, population
aging is occurring throughout the world and the number of older
persons in the world
is projected to be 2.1 billion in 2050. In Turkey, life expectancy
at birth is estimated
to be 82.5 and 89.1 years by the end of 2050 and 2100,
respectively.1 With aging,
the prevalence of diseases and geriatric syndromes increases; as
a consequence, the

elderly population is more frequently exposed to complex
medication regimens and
Correspondence: elif ertuna
Department of Clinical Pharmacy,
Faculty of Pharmacy, ege University,
35040 Bornova, Izmir, Turkey
Tel +90 532 672 5988
Fax +90 232 388 5258
email [email protected]
Journal name: Clinical Interventions in Aging
Article Designation: Original Research
Year: 2019
Volume: 14
Running head verso: Ertuna et al
Running head recto: Ertuna et al
DOI: 201039
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ertuna et al
increased drug use.2–5 Polypharmacy increases the risk of
drug-related problems (DRPs), potentially inappropriate use
of medications (PIMs), and hospitalizations, all of which are
common among elderly people.2,3,6,7
A DRP is defined as “an event or circumstance involv-
ing drug therapy that actually or potentially interferes with
desired health outcomes”.8 In addition to clinical impact,
DRPs also increase health expenditure, which causes eco-
nomic burden.9,10 Several studies have found that pharmacists
provide added value in resolving and preventing DRPs in
settings such as outpatient clinics, acute care in inpatients,
nursing homes, and palliative care.5,11–18 Studies from inpa-
tient settings have also shown that including a pharmacist
as a member of the interdisciplinary health care team may

improve outcomes and decrease drug-related readmissions
and mortality in geriatric patients.2,17,19–21 As team members,
pharmacists offer an additional perspective in the application
of medication reviews, resulting in an increase in detec-
tion of DRPs and a reduction of polypharmacy in elderly
inpatients.21
Pharmaceutical care, described as the pharmacist’s
contribution to the care of individuals in order to optimize
medicines use and improve health outcomes, is the founda-
tion of clinical pharmacy. In the past decade, changes in
pharmacy undergraduate education and new legislations in
the Turkish health care system have indicated increasing
recognition of the pharmaceutical care practice. However,
the provision of clinical pharmacy services is still a fairly
new concept. Therefore, the need to establish basic standard
operating procedures for ward-based pharmacy services and
improving efficiently delivered quality of care has emerged.
The primary objective of this study was to define and clas-

sify the DRPs and pharmacist interventions in the geriatric
ward of a teaching hospital in Turkey. The paper’s secondary
objective was to determine frequently prescribed medications
and pharmaceutical forms in relation to possible DRPs in the
study population.
Patients and methods
settings and data collection
The study was conducted between December 2017 and
July 2018 in the acute geriatric ward (10 beds) of a
government-run 1,800-bed tertiary university hospital in
Turkey. Patients aged 65 or over admitted to the outpatient
geriatric clinic or emergency department of the same hospital
with typical acute geriatric problems were hospitalized.
Referrals from other smaller district hospitals (primary or
secondary care) were also accepted. Patients were cared for
by an interdisciplinary team of geriatricians, nurses, and dieti-
cians. Medical care and discharge planning were provided.
Two licensed pharmacists working at the Department
of Clinical Pharmacy, Faculty of Pharmacy at the Ege

University began to participate in the weekly interdisciplinary
geriatric rounds in December 2017, and a medication review
service is provided routinely once a week thereafter. Phar-
macists reviewed medication orders, medication history,
and/or clinical data (such as vitals and biochemical markers)
in the medication review process to detect possible DRPs
and prepare a report of possible DRPs and interventions for
each order 1 day before weekly interdisciplinary rounds.
The reports were discussed and reviewed with a geriatrician
during the weekly interdisciplinary rounds. The acceptance
status of the proposals was then noted by pharmacists.
In the medication review process, the latest medication
orders of patients were evaluated for DRPs by software-
based, guideline-based, or knowledge-based approach by
the pharmacist. Drug–drug, food–drug, and disease–drug
interactions and intravenous incompatibilities were analyzed
with RxMediaPharma® Interactive Drug Database.22 PIM or
potentially inadequate medication use in geriatric patients

was determined using Beers criteria,23 Screening Tool of
Older Persons’ potentially inappropriate Prescriptions
(STOPP) criteria, and Screening Tool to Alert doctors to
the Right Treatment (START) criteria.24 The latest clinical
practice guidelines for specific diseases were used to support
clinical decisions when necessary.
Data analysis
The pharmacist reports for 200 medication orders of
91 patients were examined retrospectively. Problem type,
cause of problem, proposed intervention, and acceptance
status for the proposed interventions were classified accord-
ing to Pharmaceutical Care Network Europe’s (PCNE)
definitions and DRP classifications (the PCNE Classifica-
tion V 8.02).8 As using standard terms would facilitate the
comparison of the results of studies, PCNE recommends the
utilization of standard pharmaceutical care terms in European
countries.8,25,26 Detailed classification of data is shown in
Table S1 with subcategories and frequencies. One DRP may

have more than one cause and may lead to the proposition
of more than one intervention.
Definitions
A problem is defined as “the expected or unexpected event
or circumstance that is, or might be wrong, in therapy
with drugs”.8 As per definition, both manifest and possible
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problems are included in this study. Problems of a tech-
nical nature (logistic, computer error, etc.) are specified
accordingly.
The cause is defined as “the action (or lack of action) that
leads up to the occurrence of a potential or real problem”.8

The intervention is the proposed measures to be taken
to overcome the cause of the problem by the pharmacist to
prevent or solve a problem. The proposed course of action
is deemed to improve and/or maintain patients’ health and
well-being.
Acceptance is defined as the acceptance status of the
pharmacist intervention proposals evaluated by physicians.
statistical analysis
The normality of the data was analyzed using the
Kolmogorov–Smirnov test. Continuous data were described
by mean ± standard error of mean. Categorical data were
described in terms of frequencies. Correlation between the
number of DRPs and total medications per order was assessed
using Pearson’s correlation test. The number of DRPs in
orders according to age and gender and the absence or pres-
ence of renal impairment and polypharmacy were analyzed
using Student’s t-test. Data were analyzed using SPSS ver-
sion 25.0 (IBM SPSS Statistics for Windows, Version 25.0;

IBM Corp., Armonk, NY, USA). A P-value #0.05 was
considered significant.
ethical considerations
This study was approved by the Ethics Committee for
Clinical Research of Faculty of Medicine at Ege University
(Date: October 2, 2018; No: 18-10/4). All patients or their
substitute decision maker gave written informed consent for
their participation.
Results
The pharmacists’ reports for 200 medication orders of 91
patients were analyzed. A total of 55 of these patients were
admitted to the hospital for two to six consecutive weeks,
and seven patients were readmitted two to three times within
6 months after discharge. Characteristics of the patients are
presented in Table 1.
Pharmacists detected 329 possible DRPs in 156 orders
and no problem was detected in 44 orders. The PCNE cat-
egories of possible DRPs and their frequencies are shown
in Figure 1. The number of medications and DRPs per order

was not different across different age groups, genders, or
in the absence or presence of renal impairment (Table 1).
There was a significant weak positive correlation between
the number of total drugs used and the number of DRPs
per order (P,0.05, r=0.2819; Pearson’s correlation test).
Polypharmacy, described as using five or more drugs, was
present in 175 (87.5%) orders. The number of DRPs was
higher when polypharmacy was present (P,0.05; Table 1).
One DRP may have had more than one cause that led to
the recommendation of more than one intervention. A com-
plete list of combinations of causes and interventions for
each DRP is presented in Table S1. In brief, most causes
of possible DRPs were drug interactions (including IV
incompatibilities), inadequate monitoring, and a high drug
dose (Table 2).
A total of 329 interventions were proposed and/or dis-
cussed by pharmacists – 282 (85.71%) of these interventions
were proposed to the prescribers, and on 47 (14.28%) occa-

sions, the prescriber was only informed, or the intervention
was discussed with the prescriber. The most frequently
recommended intervention was monitoring, which was fol-
lowed by stopping the drug and changing dosage or instruc-
tions for use (Figure 2). A full list of PCNE categories of
the interventions is presented in Table S1. The acceptance
rate of pharmacist interventions was 85.41% (n=281). Inter-
vention was accepted and fully implemented in 223 cases
(67.78%), partially implemented in 40 cases (12.16%),
Table 1 Characteristics of patients, number of medications, and
DrPs
Medication
(mean ± SEM)
DRP
(mean ± SEM)
Patient’s age (n=200;
80.33±0.46)
8.17±0.23 1.58±0.098
65–79 years (n=78) 7.95±0.33 1.59±0.15
$80 years (n=122) 8.32±0.31 1.58±0.13

Patient’s gender
Male (n=69) 7.65±0.35 1.41±0.14
Female (n=131) 8.45±0.29 1.68±0.13
renal function
egFr .60 ml/min/1.73 m2
(n=84)
8.45±0.36 1.42±0.13
egFr #60 ml/min/1.73 m2
(n=83)
8.13±0.36 1.76±0.17
Unknowna (n=33) 7.58±0.44 1.58±0.23
number of medication per order
0–4 (n=25) 3.40±0.20 1.04±0.15
$5 (n=175) 8.86±0.21 1.66±0.11b
Notes: aUnknown at the time of medication review due to new
admission of the
patient and/or biochemistry results being incomplete at the time
of interdisciplinary
round. bP#0.05; student’s t-test (number of medications per
order; 0–4 vs $5).
Abbreviations: DrPs, drug-related problems; egFr, estimated
glomerular
filtration rate; SEM, standard error of mean.

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590
ertuna et al
not implemented in 12 cases (3.65%), and implementation
status was not known in 6 cases (1.82%). Only 38 (11.55%)
of the proposed interventions were rejected by the physician
due to being not feasible (n=19, 5.78%), unknown reasons
(n=1, 0.3%), and other reasons (n=18, 5.47%), such as the
patient being closely monitored, prior recommendations of
another specialist (psychiatry/infectious disease/cardiology),
or patient record error in hospital information system leading
to misinformation but patient receiving the correct drug form/
dosage. The acceptance status of ten intervention proposals

(3.04%) was unknown due to the physician not making the
decision during rounds and referring the patient to other
physicians for further consultations. In one case, written
information was provided only to the physician. On account
of this study being performed in a teaching hospital, medical
students also participated in the routine rounds. Pharmacist
intervention proposals led to educational discussions on six
different cases and were noted as separate interventions.
Detailed acceptance rates with respect to intervention cat-
egory are presented in Figure 2.
During this study, 1,632 medications were ordered.
Medications were coded following the WHO–Anatomical
Therapeutic Chemical (WHO–ATC) classification. ATC
groups of the most ordered drugs were N (nervous system,
358), A (alimentary tract and metabolism, 314), C (cardio-
vascular system, 304), B (blood and blood-forming organs,
197), and J (anti-infectives for systemic use, 151) (Table 3).
The number of possible DRPs for each prescribed drug in

the geriatric ward was analyzed, and the ten medications
with overall highest DRP counts and the medications with
the highest DRP counts in each ATC class were determined
(Table 3).
Pantoprazole, enteral nutrition products, enoxaparin, furo-
semide, metoprolol, sertraline, quetiapine, insulin glargine,
Figure 1 PCne categories of possible drug-related problems and
their frequencies.
Abbreviations: PCne, Pharmaceutical Care network europe;
DrPs, drug-related problems.
No problem
Not suitable strength
Wrong administration route
Ty
pe
o
f p
os
si
bl
e
D

R
P
Unnecessary drug treatment
Untreated symptom/indication
Effect not optimal
Adverse drug event possible
0 20 40 60
Percentage of possible DRPs (%)
80
Total counts
44
2
2
20
21
44
266
Table 2 PCne categories of most encountered causes of possible
DrPs and their frequencies
PCNE code PCNE category Total counts (n, %)

C 1.4 Inappropriate combination of drugs or drugs and herbal
medication (includes intravenous incompatibility) 132 (40.12%)
C 8.1 no or inappropriate outcome monitoring 47 (14.29%)
C 3.2 Drug dose too high 41 (12.46%)
C 1.2 Inappropriate drug (within guidelines but otherwise
contraindicated) 30 (9.12%)
C 8.2.1 Patient education required 28 (8.51%)
C 6.6 Drug administered via wrong route 27 (8.21%)
C 1.6 no drug treatment in spite of existing indication 23
(6.99%)
C 2.1 Inappropriate drug form (for this patient) 23 (6.99%)
C 1.1 Inappropriate drug according to guidelines/formulary 22
(6.69%)
Abbreviations: PCne, Pharmaceutical Care network europe;
DrPs, drug-related problems.
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ertuna et al
Figure 2 PCne categories of interventions proposed by the
pharmacist and their acceptance rates.
Abbreviation: PCne, Pharmaceutical Care network europe.
Table 3 Total number of ordered medications, most frequently
ordered medications, and medications with the highest number
of
possible DrPs in each ATC class
ATC class Number of ordered
medications
Most frequently ordered medication
(n, % in related ATC group)
Medications with highest DRP (possible)
counts (n, % in related ATC group)
A 314 Pantoprazole (107, 34.08%) Pantoprazole (19, 6.05%)
B 197 enoxaparin (60, 30.46%) Enoxaparin (15, 4.93%)
C 304 Furosemide (57, 18.75%) Furosemide (15, 7.61%)
Metoprolol (12, 6.09%)
D 34 silver sulfadiazine (10, 29.41%) –
g 44 Tamsulosin (19, 43.18%) silodosin (3, 6.82%)
h 53 levothyroxine (20, 37.74%) Methylprednisolone (13,

24.53%)
J 151 Ceftriaxone (26, 17.22%) Ciprofloxacin (11, 7.28%)
l 10 Methotrexate (2, 20.00%) Mycophenolate (3, 30.00%)
M 11 Allopurinol (3, 27.27%) Allopurinol (2, 18.18%)
Colchicine (2, 18.18%)
n 358 sertraline (45, 12.57%) Quetiapine (41, 11.45%)
Donepezil (27, 7.54%)
Sertraline (19, 5.31%)
Escitalopram (12, 3.35%)
P 2 Metronidazole (2, 100.00%) Metronidazole (1, 50.00%)
r 65 salbutamol + Ipratropium (26, 40.00%) Salbutamol +
Ipratropium (11, 16.92%)
s 11 Brimonidine + Timolol (4, 36.36%) –
V 78 enteral nutrition (61, 78.21%) enteral nutrition (6, 7.69%)
Total 1,632
Note: Boldface medications are the 10 medications with overall
highest possible DrP counts.
Abbreviations: DrPs, drug-related problems; ATC, Anatomical
Therapeutic Chemical.
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592
ertuna et al
acetylsalicylic acid (ASA), and parenteral nutrition were the
most frequently prescribed medications in 200 orders among
elderly patients (Figure 3). Possible drug–drug, drug–herbal
medication, food–drug interactions, and intravenous incom-
patibilities related to these medications were represented as
a percentage of possible clinically significant interactions
encountered per total number of times prescribed (Figure 3).
Only 22 PIMs, according to the Beers criteria, STOPP/
START criteria, or latest clinical practice guidelines were
prescribed during the study period. PIMs ordered on more
than one occasion were ipratropium, lorazepam, haloperidol,
ASA, and dimenhydrinate (prescribed 3, 2, 2, 2, and 2 times,
respectively). Adverse events were deemed possible in

20 of these cases, 10 of which were due to inappropriate
combinations of drugs and excessively high dosages.
On two occasions, medication was regarded unnecessary
by the pharmacist. Intervention proposals to stop or change
drugs, monitor effects, or educate patients were accepted in
19 (86.36%) occasions (Table S1).
The appropriateness of the drug formulation for each
patient was also evaluated and coded following NFC
(EphMRA [The European Pharmaceutical Market Research
Association] New Form Code) classification. Only 23 drug
formulations were interpreted as inappropriate by phar-
macists. For the most part, swallowing difficulties among
patients or crushing or splitting of oral solid ordinary film-
coated tablets (ABC, n=15), oral solid retard film-coated
tablets (BBC, n=3), oral solid ordinary enteric-coated tablets
(ABD, n=2), and oral solid retard tablets (BAA, n=2) caused
the problem. Finally, as intramuscular injection is not a favor-
able route of administration in the elderly, prescription of a

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